Most forms can be completed directly on your computer and printed for faxing or mailing to HMSA.
The first column of the table below contains links to documents that describe or otherwise refer to the listed forms. The second column contains links to the actual forms or location where the forms can be accessed.
Access the QUEST Integration - Forms Index.
| Description, Instructions or Other Information | Link to Form | Provider Type |
|---|---|---|
| Access Request and Contract to Preserve Confidential Information Form | Form [PDF] | Multiple |
| Affordable Care Act (ACA) Fax Order Form for Women's Preventive Health Services Materials | Form [PDF] | Multiple |
| Agent Authorization | Multiple | |
| Acknowledgement of Financial Responsibility - Medical | Multiple | |
| Appealing a Precertification/Prior Authorization Denial | Multiple | |
| Appealing Processed Claims | Multiple | |
| Applied Behavior Analysis (ABA) Precertification/Prior Authorization Request Form | Form [PDF] | |
| Apply to HMSA | Forms | Provider Enrollment |
| Authorization of Release of Records or Information (no instructions available) | Behavioral Health | |
| Authorization to Release Documents and Information and Dispute Resolution Agreement Form | Form [PDF] | |
| Bone (Mineral) Density Studies | Medical | |
| Breast Tomosynthesis Waiver | Form [PDF] | Medical |
| CAAP - Care Access Assistance Program Instructions | Instructions [PDF] | Medical |
| *CAAP - Care Access Assistance Program Form | Medical | |
| *CAAP - Carpenters' Mainland Travel Request Form (no instructions available) | Medical | |
| Care Denial Letter | Home Health | |
| Care for Older Adult (COA) Assessment | Form [PDF] | |
| Care Management Programs Referral Form | Form [PDF] | Medical |
| Change in Provider Status – HMO Health Center Use Only | Form [PDF] | |
| Change to HHIN Provider List Form | Form [PDF] | |
| Clinical Review Request Form | Form [PDF] | |
| CMS 1500 - Interactive (instructions incorporated into form) | Multiple | |
| CMS-1696 - Appointment of Representative Form | Form [PDF] | |
| Coordination of Benefits (COB) Subscriber Questionnaire (no instructions available) | Multiple | |
| Detailed Explanation of Noncoverage | Multiple | |
| Detailed Notice of Discharge | Facility | |
| Documentation Necessary for Continuation of Oxygen | Form [PDF] | Multiple |
| Documentation Worksheet | Multiple | |
| Drug Review Request | Medical | |
| Electronic Funds Transfer | Medical | |
| Electronic Remittance Advice | Medical | |
| Electronic Trading Partner Agreement Form | Form [PDF] | Multiple |
| Electronic Trading Partner - Business Associate Authorization Form | Form [PDF] | Multiple |
| E/M Worksheet | Form [PDF] | Multiple |
| Federal Employee Health Benefits (FEHB) Plans and Postal Service Health Benefits (SPHB) Plans - Surgical Contraception Exception Form | Form [PDF] | Medical |
| Form 97 - Unable to Process Claims | Form [PDF] | Multiple |
| HMO Administrative Review (Same as Precertification/Prior Authorization general form) | Form [PDF] | Multiple |
| HMSA Akamai Advantage® Non-Contracted Provider Waiver of Liability Statement | Form [PDF] | Multiple |
| HMSA Hepatitis C Treatment Checklist | Form [PDF] | Medical |
| HMSA Member Agreement of Financial Responsibility | Form [PDF] | Medical |
| Home Health Assessment - QUEST Integration | Form [PDF] | Medical |
| *HPH/HMO Travel Registry Form | Multiple | |
| *HSTA Travel Assistance Reimbursement Request Form | Form | Multiple |
| *ILWU Travel Request Form | Form | Medical |
| Important Message from Medicare | Facility | |
| Injury/Illness Report Form | Multiple | |
| Integrated Denial Notice (Notice of Denial of Medical Coverage, NDMC) | Facility | |
| IV/Injectables Drug Review Form | Form [PDF] | |
| IV Therapy Cover Sheet | Home IV therapy | |
| In Vitro Fertilization | Medical | |
| Long-Term Services and Supports (LTSS) Referral Form | Form [PDF] | |
| Magellan Hawai’i | Form [PDF] | Behavioral Health |
| Magellan Hawai’i PCP Referral Form | Form [PDF] | Behavioral Health |
| Mail Order Prescription Drug Program | Medical | |
| Medicare Advantage Annual Wellness Visit Form | Form [PDF] | Multiple |
| Medicare Advantage Non-Contracted Provider Appeal and Payment Dispute Request | Form [PDF] | Multiple |
| Medicare Advantage Non-Contracted Provider Waiver of Liability Statement | Form [PDF] | Multiple |
| Medicare Part D Coverage Determination Request Form | Form [PDF] | |
| Medicare Outpatient Observation Notice (MOON) Form CMS-10611 | Form [ZIP] | |
| Medication Reconciliation Post-Discharge (Medicare) | Form [PDF] | |
| Member Requests for Confidential Communication | Form [PDF] | Medical |
| Minor’s Mental Health Non-Disclosure Form | Form [PDF] | Behavioral Health |
| Notice of Denial of Medical Coverage (NDMC) | ||
| Notice of Medicare Noncoverage (NOMNC) | Facility | |
| Physician Quality Recognition Survey | Form [PDF] | Medical |
| Precertification/Prior Authorization Request - Behavioral Health Services | Form [PDF] | Facility |
|
Precertification/Prior Authorization Request - General Use this form only if no other precertification/prior authorization request form applies. |
Medical | |
| Precertification/Prior Authorization Request - Hemophilia A and B Blood Products | Form [PDF] | Medical |
| Precertification/Prior Authorization Request - Home IV Therapy | Home IV therapy | |
| Precertification/Prior Authorization Request - Post Acute Care Services | Form [PDF] | Facility |
| Physician Orders for Life-Sustaining Treatment (POLST) | Medical | |
|
Providers can now submit requests for these requests online. Go to Provider Self-Service. |
Additional Location Form [PDF] Change in Provider Panel Form [PDF] Change in Specialty Form [PDF] |
|
| QUEST Integration Health Coordination Services Referral Form | Form [PDF] | Medical |
| Request for Fee Review | Medical | |
| Request for Restriction of Minor's Reproductive Health Information | ||
|
Student's Health Record - FORM 14 This is the official health record for all students in the public school system. FORM 14 contains the necessary requirements for 7th grade school entry. Every student is required to submit a health record upon entry into the 7th grade public school system. |
Form [PDF] | |
| Supportive Care | Form [PDF] | Medical |
| UB-04 Claim Form - General Instructions | Facility | |
| Vaccine Additional Payment Request | Medical |
*HMSA’s Travel Request Forms have moved to the Hawaii Healthcare Information Network (HHIN+) online at https://hhinplus.hmsa.com. The Travel Request module is found in the “Others” tab on the HHIN+ home page. If you do not see the Travel button or if you need help navigating HHIN+ please contact HMSA Electronic Transaction Services at 808-948-6255 or email ETSOutreach@hmsa.com.
Revision History
| Date | Nature of Revision |
|---|---|
| 08/03/2026 | Migrated to new platform |